Although a US advisory panel no longer recommends that men routinely undergo prostate cancer screening with a PSA blood test, men should ask their doctors for the exam if they're uncomfortable without monitoring, health experts say.
Urologists and cancer experts dismissed the idea that the US Preventive Services Task Force's criticism of the PSA test will set a man's personal agenda or interfere with doctor-patient relationships. They acknowledged, however, that health insurers are likely to take notice of the new recommendation, released in the journal Annals of Internal Medicine, and potentially alter coverage of the screening test.
In abandoning earlier guidelines that called for screening to start at 50, the task force said the PSA test does more harm than good, resulting in overdiagnosis of many slow-growing cancers while prompting aggressive treatment that can leave men impotent or incontinent. The test measures blood levels of prostate-specific antigen, a protein produced by the prostate gland.
Judicious use of potentially risky tests and treatments can help mitigate those problems, said Dr Sandip Prasad, a urologic oncology research fellow at the University of Chicago Medical Center.
"As we adopt smarter treatment strategies ... the goal is always to identify men who are going to die of prostate cancer. Taking away the PSA reduces our ability to do that," Prasad said. "Most of us are very open with our patients about the limits of PSA testing. Screening doesn't have to get this big ball rolling that takes you to the bottom of a hill."
About 28 000 American men will die of prostate cancer – the second most common malignancy in men -- this year, according to the US National Cancer Institute. Despite the PSA test's high false-positive rate, which can trigger painful and unnecessary biopsies, no other reliable screening test exists to detect prostate cancer.
Testing for the presence of prostate cancer
Patients should discuss any concerns about testing – or not testing – with their doctor, experts said.
Dr Otis Brawley, chief medical officer of the American Cancer Society, said better tests to determine not only the presence of prostate cancer but each case's true threat to patients have been held back from development because of the fixation on PSA testing. But Brawley and other experts said such future tests will likely focus on the specific genes at play in the malignancy.
"Truth be told, prostate cancer screening as a whole, and its progress, has been delayed because so many people have been adamant about doing PSA screening in the last 20 years and not assessing if it works," Brawley said.
Prasad called it "stunning" that imaging tests such as CT or MRI scans aren't often used to detect prostate cancer, as they are for many other malignancies.
"If we go back to diagnosing with symptoms ... it seems like a tremendous step backward," he said.
"Without the PSA, obviously we will diagnose fewer and fewer men," Prasad added. "But for the guys [in which] you pick it up five, seven or 10 years earlier, you can save their life. As physicians, we're called on to do that as best we can."
Identifying aggressive prostate cancer
A better test will come, Brawley said, noting that "the science has advanced so much in the last five years."
Dr Anthony D'Amico, chief of radiation oncology at Brigham and Women's Hospital in Boston, said pathology guidelines are needed that would better identify aggressive prostate cancers from less harmful versions.
"PSA diagnoses every cancer that walks, and not every prostate cancer that walks needs to be cured," he said. "The solution lies at the level of the pathologist... We need to sit down with them and come up with guidelines [about what constitutes high-grade prostate cancer]. It can be done, but it needs to be worked on."
Until then, some physicians fear that insurance companies will cut off coverage of the PSA test, creating a devastating disparity between those who can afford to pay for it out of pocket and those who can't. The latter group likely will include minorities and senior citizens, who already are at higher risk for developing prostate cancer.
"Older black and Hispanic men are going to have increases in prostate cancer because they won't have the opportunity for early detection," D'Amico said. "So I think we should screen high-risk populations, because we know who they are."
(Maureen Salamon, HealthDay, May 2012)
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